Healthcare Provider Details

I. General information

NPI: 1972027688
Provider Name (Legal Business Name): MERCY MANAGEMENT OF SEPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S 54TH ST STE 26
PHILADELPHIA PA
19143-1900
US

IV. Provider business mailing address

1 W ELM ST
CONSHOHOCKEN PA
19428-4108
US

V. Phone/Fax

Practice location:
  • Phone: 215-748-9200
  • Fax: 215-748-9307
Mailing address:
  • Phone: 610-567-6964
  • Fax: 610-567-5420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMIEE BRENNAN
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 610-567-6964